Does Strattera Increase Blood Pressure?
Yes, Strattera (atomoxetine) does increase blood pressure and heart rate, and this effect requires careful monitoring, particularly in the first weeks of treatment. 1
Magnitude of Blood Pressure Effects
The FDA label for atomoxetine explicitly warns that approximately 5-10% of pediatric patients experience potentially clinically important changes in blood pressure (≥15-20 mm Hg) or heart rate (≥20 beats per minute). 1
In controlled clinical trials, atomoxetine was associated with statistically significant increases in mean systolic blood pressure in adults and diastolic blood pressure in children and adolescents, though these increases were described as small in magnitude. 2
Research demonstrates that atomoxetine causes mean increases of 2-4 mm Hg in blood pressure and 4-6 beats per minute in heart rate, with these changes typically occurring early in therapy and stabilizing over time. 3, 2
High-Risk Populations
Atomoxetine is absolutely contraindicated in patients with pheochromocytoma or severe cardiovascular disorders, as it can cause serious reactions including elevated blood pressure and tachyarrhythmias. 1
The FDA label specifically states that atomoxetine should not be used in patients with severe cardiac or vascular disorders whose condition would be expected to deteriorate with clinically important increases in blood pressure (15-20 mm Hg) or heart rate (20 beats per minute). 1
In patients with central autonomic failure, even low pediatric doses (18 mg) of atomoxetine can cause dramatic blood pressure increases—one study showed seated systolic blood pressure increases of 54±26 mm Hg, with some patients reaching systolic pressures as high as 209 mm Hg. 4
Patients with impaired central autonomic function lack the compensatory sympatholytic mechanisms that normally prevent hypertension with atomoxetine, making them particularly vulnerable to severe pressor effects. 4
Clinical Monitoring Requirements
All patients receiving atomoxetine must have blood pressure and heart rate monitored at baseline and periodically throughout treatment, with particular vigilance during the first 12 weeks. 1
The International Society of Hypertension guidelines recommend screening all patients with hypertension or at risk for hypertension for medications that may increase blood pressure, including sympathomimetics like atomoxetine. 5
Blood pressure increases with atomoxetine tend to occur early in therapy, stabilize, and return toward baseline upon drug discontinuation. 2
Poor CYP2D6 metabolizers (approximately 7% of Caucasians) have greater exposure to atomoxetine and may experience more pronounced cardiovascular effects, requiring closer monitoring. 3
Mechanism and Clinical Context
Atomoxetine increases blood pressure through its selective inhibition of presynaptic norepinephrine reuptake, which elevates synaptic norepinephrine concentrations in both central and peripheral sympathetic neurons. 3, 4
While the 2020 International Society of Hypertension guidelines do not specifically list atomoxetine in their table of drug exacerbators of hypertension, they do include sympathomimetics as a category that increases blood pressure. 5
The cardiovascular effects are generally minimal and well-tolerated in patients without underlying cardiovascular disease or autonomic dysfunction. 2
Management Approach
If atomoxetine is required in a patient with hypertension, blood pressure should be treated to target regardless, but the medication should be avoided entirely in patients with uncontrolled hypertension or severe cardiovascular disease. 5, 1
Consider alternative ADHD treatments in patients with pre-existing hypertension, cardiovascular disease, or autonomic dysfunction. 1
If atomoxetine must be used, ensure blood pressure is well-controlled before initiation and monitor closely during dose titration. 1
Discontinue atomoxetine if clinically significant blood pressure or heart rate elevations occur that cannot be managed with adjustment of antihypertensive therapy. 1